Progress to be made in asthma management
Authors: Mariëlle W Pijnenburg, Ian Pavord
Journal: The Lancet Global Health (2023)

In The Lancet Global Health, the Global Asthma Network (GAN), presents worldwide, cross-sectional data on asthma control and asthma treatments in three age groups: children (aged 6–7 years), adolescents (13–14 years), and adults (≥19 years).1García-Marcos L Chiang C-Y Asher MI et al.Asthma management and control in children, adolescents, and adults in 25 countries: a Global Asthma Network Phase I cross-sectional study.Lancet Glob Health. 2023; 11: e218-e228Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar The results indicate high rates of poor asthma control across all age groups and country income categories, with particularly high rates in children and in countries with low gross national income. Additionally, overall uptake of inhaled corticosteroids was low, and use of oral medications, such as oral short-acting β2-agonists (SABA) and theophylline, was frequently reported. A call for action to improve asthma management has existed for many years. These recent data are disappointing and make us cynical as to whether progress will be made. Why are we not making any progress in reducing the worldwide burden of asthma, despite high-quality international and national guidelines, and effective inhaled asthma medications? First, as discussed by Luis García-Marcos and colleagues,1García-Marcos L Chiang C-Y Asher MI et al.Asthma management and control in children, adolescents, and adults in 25 countries: a Global Asthma Network Phase I cross-sectional study.Lancet Glob Health. 2023; 11: e218-e228Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar the availability and affordability of inhaled medicines and appropriate devices in low-income countries (LICs) and middle-income countries (MICs) are important issues. A recent systematic review showed that only 10% of LICs and MICs met the WHO availability target of 80% for inhaled SABA, at a price of approximately 1–4 days’ wages; for inhaled corticosteroids, only 6% of LICs and MICs met the WHO availability target (also 80%), at a price of 2–7 days’ wages.2Stolbrink M Thomson H Hadfield RM et al.The availability, cost, and affordability of essential medicines for asthma and COPD in low-income and middle-income countries: a systematic review.Lancet Glob Health. 2022; 10: e1423-e1442Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar In a study from Nigeria, the medicines that were available and affordable were oral salbutamol (a SABA) and oral corticosteroids, both of which are not on the WHO essential medicines list.3Ozoh OB Eze JN Garba BI et al.Nationwide survey of the availability and affordability of asthma and COPD medicines in Nigeria.Trop Med Int Health. 2021; 26: 54-65Crossref PubMed Scopus (7) Google Scholar The GAN authors pleaded for engagement of all stakeholders to improve the availability and affordability of safe and effective asthma medications in LICs and MICs, which can only be strongly supported by the respiratory community. However, these barriers do not explain the higher use of oral SABA and oral corticosteroids in high-income regions versus low-income and lower-middle-income regions in all age groups.1García-Marcos L Chiang C-Y Asher MI et al.Asthma management and control in children, adolescents, and adults in 25 countries: a Global Asthma Network Phase I cross-sectional study.Lancet Glob Health. 2023; 11: e218-e228Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar We can only speculate on the causes for this outcome, but believe the only plausible reason is poor uptake of guidelines, which underlines the need for effective guideline implementation plans and strong national asthma action plans.4Selroos O Kupczyk M Kuna P et al.National and regional asthma programmes in Europe.Eur Respir Rev. 2015; 24: 474-483Crossref PubMed Scopus (80) Google Scholar Second, GAN data are based on validated questionnaires, following the same methodology as in the International Study of Asthma and Allergies in Childhood (ISAAC). The study approach of sampling data is an important strength as it facilitates the inclusion of a high number of individuals (n=453 473 overall, n=25 654 with asthma) and makes comparison with earlier studies (ie, those from ISAAC) possible. However, a limitation of this methodology is that asthma diagnosis is not based on objective criteria such as spirometry as recommended by recent guidelines on asthma diagnosis in children and adults from the European Respiratory Society.5Gaillard EA Kuehni CE Turner S et al.European Respiratory Society clinical practice guidelines for the diagnosis of asthma in children aged 5–16 years.Eur Respir J. 2021; 582004173Crossref PubMed Scopus (56) Google Scholar, 6Louis R Satia I Ojanguren I et al.European Respiratory Society guidelines for the diagnosis of asthma in adults.Eur Respir J. 2022; 602101585Crossref PubMed Scopus (34) Google Scholar Therefore, overdiagnosis of asthma might be an issue in this analysis, in particular in asymptomatic and mildly symptomatic patients (68–73% of the included population). In these patients overtreatment with asthma medications might be an issue, as asthma has not been diagnosed by objective tests. With inexpensive handheld spirometers, an objective asthma diagnosis can be made, which would help to identify patients who might benefit from inhaled asthma medications such as SABA and corticosteroids. Third, in this study no data are available on biomarkers such as the fraction of exhaled nitric oxide (FeNO) or blood eosinophils. The recent Lancet Commission on asthma suggested several ways to improve asthma treatment, and recommended the use of biomarker-directed risk stratification,7Pavord ID Beasley R Agusti A et al.After asthma: redefining airways diseases.Lancet. 2018; 391: 350-400Summary Full Text Full Text PDF PubMed Scopus (620) Google Scholar targeted treatment rather than the current one-size-fits-all anti-inflammatory approach, and abandoning outdated treatment escalations (including the step-up approach). Symptoms are known to be a poor predictor of the risk of asthma exacerbations, and different mechanisms are widely established to be involved, with type 2 inflammation (a common, recognisable, and treatable trait) being particularly associated with risk of asthma attacks and declines in lung function.8Couillard S Laugerud A Jabeen M et al.Derivation of a prototype asthma attack risk scale centred on blood eosinophils and exhaled nitric oxide.Thorax. 2022; 77: 199-202Crossref PubMed Scopus (36) Google Scholar, 9Petousi N Wooden A Russell REK A new piece in the puzzle: the eosinophil and the development of COPD.Eur Respir J. 2021; 582101105Crossref PubMed Scopus (4) Google Scholar Furthermore, all other factors being equal, a patient with raised blood eosinophils and FeNO has a 4-times increased risk of an asthma attack, and will lose forced expiratory volume in 1 s at a 3-times increased rate over time.8Couillard S Laugerud A Jabeen M et al.Derivation of a prototype asthma attack risk scale centred on blood eosinophils and exhaled nitric oxide.Thorax. 2022; 77: 199-202Crossref PubMed Scopus (36) Google Scholar, 9Petousi N Wooden A Russell REK A new piece in the puzzle: the eosinophil and the development of COPD.Eur Respir J. 2021; 582101105Crossref PubMed Scopus (4) Google Scholar Both issues are effectively prevented by inhaled corticosteroids. Widespread adoption of biomarker-directed care would allow clinicians to identify and target patients with poor long-term prognoses. We acknowledge that spirometry, FeNO measurements, and even blood eosinophils are not widely available in LICs and MICs. However, these measurements are not expensive and are likely to be cost-effective by resulting in more effective and efficient use of inhaled corticosteroids.10Petsky HL Cates CJ Kew KM Chang AB Tailoring asthma treatment on eosinophilic markers (exhaled nitric oxide or sputum eosinophils): a systematic review and meta-analysis.Thorax. 2018; 73: 1110-1119Crossref PubMed Scopus (108) Google Scholar Perhaps the time is right to fundamentally reconsider about how we as clinicians approach the problem of asthma management, to work towards adopting a biomarker-based treatment strategy. Depending on the global region, increased availability and affordability of asthma medications, improved implementation of guidelines, objective asthma diagnosis, and biomarker-guided management are all strategies that could reduce the global burden of asthma. If these strategies are implemented, we might finally see a global survey that shows improvements in outcomes. We believe the time is right for more radical action, as was called for in the Lancet Commission on asthma. MWP reports other support from Sanofi, AbbVie, and Novartis, outside the submitted work. IP reports other support from Sanofi and Regeneron Pharmaceuticals and non-financial support from Excerpta Medica, during the conduct of the study. IP also reports grants and other from Chiesi and other support from Aerocrine AB, Almirall, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Novartis, Regeneron Pharmaceuticals, Sanofi, Teva, Circassia, Dey Pharma, Genentech, Knopp Biosciences, Merck, Merck Sharp & Dohme, Napp Pharmaceuticals, RespiVert, and Schering-Plough, outside the submitted work. Asthma management and control in children, adolescents, and adults in 25 countries: a Global Asthma Network Phase I cross-sectional studyAsthma management and control is frequently inadequate, particularly in low-resource settings. Strategies should be implemented to improve adherence to asthma treatment guidelines worldwide, with emphasis on access to affordable and quality-assured essential asthma medicines especially in low-income and middle-income countries. Full-Text PDF Open Access